=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528545258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J COLE WHITE DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2018
-----------------------------------------------------
Last Update Date | 07/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2868 W MARTIN LUTHER KING BLVD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72704-7625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-249-8181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2868 W MARTIN LUTHER KING BLVD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72704-7625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUSTIN WHITE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 479-270-2878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 3780
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------